Healthcare Provider Details

I. General information

NPI: 1013429778
Provider Name (Legal Business Name): GRACE E. RUDERSDORF, DDS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11290 W ALAMEDA AVE STE A-100
LAKEWOOD CO
80226-2575
US

IV. Provider business mailing address

11290 W ALAMEDA AVE STE A-100
LAKEWOOD CO
80226-2575
US

V. Phone/Fax

Practice location:
  • Phone: 303-237-1553
  • Fax: 303-232-1683
Mailing address:
  • Phone: 303-237-1553
  • Fax: 303-232-1683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number202316
License Number StateCO

VIII. Authorized Official

Name: DR. GRACE RUDERSDORF
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 303-237-1553